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11) <br /> J, <br /> kY <br /> ONSITE WASTEWATER TREATMENT SYSTEM PERMIT 17( <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 384 E WEBER AVE-3Y1 FL-STOCXTON CA 95202 - (209)468-3420 <br /> NQN-REFLINDABLE PERMIT CA L 209 953-7697 FOR INSPECTIONS EXPIR 1 YEAR FROM DATE ISSUED <br /> 952 <br /> JOB ADDRESS O S • C.T'/ZIP - n <br /> APN �r7 /X/ '• O� PARCELSIZE <br /> CwOea 6TRee'r - ---- --- <br /> _. OWNER NAME. / PHONNE^^ ' <br /> OWNER ADDRESS � CITVNTATE1ZIP "�'CJT <br /> CONTRACTOR / PHONE <br /> CONTRACTOR ADDRESS CfTY'STATE/ZIP 1 <br /> LICENSE ❑C-02 ❑C•36 OTHER _ NUMBER EXPIRATION DATE_ } <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST #_.j <br /> BUILDING PERMIT# LAND USE APPLICATION#_ <br /> TYPE OF WORK: ❑ ---ELATION <br /> ❑ REPAIR/AIHNTION ❑ ENGINEER DESIGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESITIUmoh <br /> INSTALLATION WILL SERVE: O RESIDENCE COMMERCIAL. X OTHER <br /> NVMBEROFLIVINGUNITS: NUMBER OF BEDROOMS: NUMBF.ROF EMPt.OYEES: <br /> SEPTIC TANK TYPFIMFG CAPACITY _ �._ gal #OFCOMPARTMENTS <br /> ❑ GREASE TRAP TYPFIMFG —__ CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKG TX PLANT DISTANCE TO NEAREST: WELL_._ It FOUNDATION R PROPERTY LME R (\f <br /> ❑ LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) � <br /> LEACH LINES LILEACHING CHAMBERS s #of LINES `+ LENGTH OF LINES <br /> DISTANCE TO NEAREST WELL J R FOUNDATION IBD / It PROPERTY LME <br /> ❑ FILTER BED WIrrn, ft LLNOTH R DEPTH ft (�\ <br /> DLRrANCETO NEARER! WEI.I. ft FOUNDATION R PROPERTY LINE <br /> ❑ MOUNDED WIDTH ft LENGTH ft DFJ'rH ft <br /> DISTANCE.TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH It <br /> DISTANCE TO NEAREST WELL R FOUNDATION R PROPERTY LINE ft <br /> ❑ DISPOSAL PONDS wttmt ft LENGTH __^ft DEPTH ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION_ R PROPERTY LME ft <br /> ❑ SEEPAGE PITS NUMBER WIDTH_ ft DEPTH __ ft <br /> DISTANCETONEARFST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUN-IY <br /> O DINANCM STATE LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY: <br /> MINI 4Y HOUR ADVANCE NOTICE.REQUIRED FOR INSPECTIONS-PLEASE CALL 1209)953-7697 <br /> SIGNED <br /> TITLE V'�- DATE ( J Z <br /> w - <br /> .� -.r_rar..e D.• <br /> lao+'E1+n' ohAlnr au. <br /> uar wrrcr aoac rA PP[ <br /> PAYMtro omr«a uAc++tan <br /> NSiNl—Da ,— — _ — OCT 15. <br /> m.N 1 six ee PlPi. AQUI <br /> rr": NLEf,+is oN. SAN JO <br /> -' NSTAl+Tao adL ENVIRON <br /> .+s,ul,m•ItACN,>K <br /> 0,,) I <br /> airuR-r.t+Zu.n. HEALTH DEI <br /> n,a aar�wu. <br /> X <br /> �M-c No.25835 <br /> Exp. 12-31-05 <br /> ,, 9�r�L1fG��,\Q' <br /> (PICAL D15POSAL TREND <br /> PL <br /> >•— D ARTMENT USE ONLY / <br /> Application Acce <br /> Date — -e Area Employee ION <br /> Final)nspect By __ Date ����O y ❑ SPECIAL PERMIT-Approved by __� •n4 <br /> Character of Sol o Depth Df 3 Pit/Sump SDII Character. <br /> COMMENTS -�'�� "`t. � <br /> PE SC Received hecW)! .Amount I�f< Peratit/ In Wee# P D# <br /> Code INFO B s Remitted Service R ueet# <br /> t S 0 3V !° <br /> �s6a- D39eI S <br /> ONSITE WASTEWATER PERMIT <br /> 42-02-001 <br /> 12J22f2003 <br />